normal spontaneous delivery procedure

After delivery of the head, the infants body rotates so that the shoulders are in an anteroposterior position; gentle downward pressure on the head delivers the anterior shoulder under the symphysis. Diseases and conditions: placenta previa. Some read more ) tend to be more common after forceps delivery than after vacuum extraction. For manual removal, the clinician inserts an entire hand into the uterine cavity, separating the placenta from its attachment, then extracts the placenta. 1. Induced vaginal delivery: Drugs or other techniques start labor and soften or open your cervix for delivery. A. LeFevre ML: Fetal heart rate pattern and postparacervical fetal bradycardia. Clamp cord with at least 2-4 cm between the infant and the closest clamp. If the placenta has not been delivered within 45 to 60 minutes of delivery, manual removal may be necessary; appropriate analgesia or anesthesia is required. Explain the procedure and seek consent according to the . This teaching approach may lead to poor or incomplete skill . Spontaneous vaginal delivery at term has long been considered the preferred outcome for pregnancy. Contractions soften and dilate the cervix until its flexible and wide enough for the baby to exit the mothers uterus. Fetal risks with vacuum extraction include scalp laceration, cephalohematoma formation, and subgaleal or intracranial hemorrhage; retinal hemorrhages and increased rates of hyperbilirubinemia have been reported. The cord should be double-clamped and cut between the clamps, and a plastic cord clip should be applied about 2 to 3 cm distal from the cord insertion on the infant. Within an hour, the mother pushes out her placenta, the organ connecting the mother and the baby through the umbilical cord and providing nutrition and oxygen. To advance the head, the clinician can wrap a hand in a towel and, with curved fingers, apply pressure against the underside of the brow or chin (modified Ritgen maneuver). The 2nd stage of labor is likely to be prolonged (eg, because the mother is too exhausted to bear down adequately or because regional epidural anesthesia inhibits vigorous bearing down). Bonus: You can. Third- and 4th-degree perineal tears (1 Delivery of the fetus references Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. Episiotomy prevents excessive stretching and possible irregular tearing of the perineal tissues, including anterior tears. Active management includes giving the woman a uterotonic drug such as oxytocin as soon as the fetus is delivered. Use for phrases Encourage the mother to void before delivery to reduce the discomfort. Bex PJ, Hofmeyr GJ: Perineal management during childbirth and subsequent dyspareunia. (See also Postpartum Care and Associated Disorders Postpartum Care Clinical manifestations during the puerperium (6-week period after delivery) generally reflect reversal of the physiologic changes that occurred during pregnancy (see table Normal Postpartum read more .). Some read more ). If anesthesia is local (pudendal block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. This 5-minute video demonstrates a normal, spontaneous vaginal delivery. There are different stages of normal delivery or vaginal birth that include: The cord may continue to pulsate for several minutes, supplying the baby with oxygen while she establishes her own breathing. Don't automatically initiate continuous electronic fetal heart rate monitoring during labor for women without risk factors; consider intermittent auscultation first. Oxytocin should not be given as an IV bolus because cardiac arrhythmia may occur. Procedures; Contraception; Support; About; Index; Search for: Vaginal Delivery . Women giving birth for the first time tend to go through labor for 12 to 24 hours, while women who have previously delivered a child may only go through labor for 6 to 8 hours.These are the three stages of labor that signal a spontaneous vaginal delivery is about to occur: Of the almost 4 million births that occur in the United States each year, most are spontaneous vaginal deliveries. Indications for forceps and vacuum extractor are essentially the same. Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection. The uterus is most commonly inverted when too much traction read more . Thus, the clinician controls the progress of the head to effect a slow, safe delivery. Enter search terms to find related medical topics, multimedia and more. Treatment depends on etiology read more , which is a leading cause of maternal morbidity and mortality. Reanalysis of data from the National Collaborative Perinatal Project (including 39,491 deliveries between 1959 and 1966) and new data from the Consortium on Safe Labor (including 98,359 deliveries between 2002 and 2008) have led to reevaluation of the normal labor curve. Learn more about the MSD Manuals and our commitment to, Cargill YM, MacKinnon CJ, Arsenault MY, et al, Fitzpatrick M, Behan M, O'Connell PR, et al, Towner D, Castro MA, Eby-Wilkens E, et al. The woman's partner or other support person should be offered the opportunity to accompany her. Second-degree laceration repairs are best performed in a continuous manner with absorbable synthetic suture. These problems usually improve within weeks but might persist long term. It becomes concentrated in the fetal liver, preventing levels from becoming high in the central nervous system (CNS); high levels in the CNS may cause neonatal depression. The infant is thoroughly dried, then placed on the mothers abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet. Episioproctotomy (intentionally cutting into the rectum) is not recommended because rectovaginal fistula is a risk. Pudendal block, rarely used because epidural injections are typically used instead, involves injecting a local anesthetic through the vaginal wall so that the anesthetic bathes the pudendal nerve as it crosses the ischial spine. Cargill YM, MacKinnon CJ, Arsenault MY, et al: Guidelines for operative vaginal birth. Treatment depends on etiology read more , occur at this time, and frequent observation is mandatory. More research on the safety and effectiveness of this maneuver is needed. With thiopental, induction is rapid and recovery is prompt. Complications of pudendal block include intravascular injection of anesthetics, hematoma, and infection. An induced vaginal delivery is a delivery involving labor induction, where drugs or manual techniques are used to initiate labor. 2. It is used mainly for 1st- or early 2nd-trimester abortion. Epidural analgesia, which can be rapidly converted to epidural anesthesia, has reduced the need for general anesthesia except for cesarean delivery. Normal Spontaneous Delivery - Excessive lochia - Vaginal tear and soreness If the fetus is in the occipitotransverse or occipitoposterior position in the second stage, manual rotation to the occipitoanterior position decreases the likelihood of operative vaginal and cesarean delivery.26 Fetal position can be determined by identifying the sagittal suture with four suture lines by the anterior (larger) fontanelle and three by the posterior fontanelle. Vaginal delivery is the most common type of birth. Use to remove results with certain terms ICD-10-CM Coding Rules Labor opens, or dilates, her cervix to at least 10 centimeters. Diagnosis is clinical. Mayo Clinic Staff. Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. Fitzpatrick M, Behan M, O'Connell PR, et al: Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery. When epidural analgesia is used, drugs can be titrated as needed during the course of labor. Pushing can begin once the cervix is fully dilated. J Obstet Gynaecol Can 26 (8):747761, 2004. https://doi.org/10.1016/S1701-2163(16)30647-8, 2. Because potent and volatile inhalation drugs (eg, isoflurane) can cause marked depression in the fetus, general anesthesia is not recommended for routine delivery. Some read more ) and anal sphincter injuries (2 Delivery of the fetus references Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. Maternal age with Gravida and Parity; Gestational age, weight, and Sex; Fetal Vertex Position; APGAR Score; Time and date of delivery; Episiotomy or Perineal Laceration. prostate. After delivery, the woman may remain there or be transferred to a postpartum unit. A cesarean section is a surgical incision through the mother's abdomen and uterus to deliver one or more fetuses. Some read more ). Repair second-degree perineal lacerations with a continuous technique using absorbable synthetic sutures. 1. However, use of episiotomy is decreasing because extension or tearing into the sphincter or rectum is a concern. Compared with interrupted sutures, continuous repair of second-degree perineal lacerations is associated with less analgesia use, less short-term pain, and less need for suture removal.45 Compared with catgut (chromic) sutures, synthetic sutures (polyglactin 910 [Vicryl], polyglycolic acid [Dexon]) are associated with less pain, less analgesia use, and less need for resuturing. 1. Oxytocin should not be given as an IV bolus because cardiac arrhythmia may occur. Options include regional, local, and general anesthesia. If the placenta is incomplete, the uterine cavity should be explored manually. Search dates: September 4, 2014, and April 23, 2015. This block anesthetizes the lower vagina, perineum, and posterior vulva; the anterior vulva, innervated by lumbar dermatomes, is not anesthetized. Active management of the 3rd stage of labor reduces the risk of postpartum hemorrhage Postpartum Hemorrhage Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours of birth. Please confirm that you are a health care professional. 7. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Remove loose objects (e.g. Every delivery is unique and may differ from mothers to mothers. Uterotonic drugs help the uterus contract firmly and decrease bleeding due to uterine atony, the most common cause of postpartum hemorrhage. Diagnosis is clinical. The mother can usually help deliver the placenta by bearing down. Episiotomy, An episiotomy is a surgical cut made in the perineum during childbirth. You are in active labor when the contractions get longer, stronger, and closer together. Then, the infant may be taken to the nursery or left with the mother depending on her wishes. Infiltration of the perineum with an anesthetic is commonly used, although this method is not as effective as a well-administered pudendal block. 7. Empty bladder before labor Possible Risks and Complications 1. False A Which procedure is coded to the Medical and Surgical section? However, traditional associative theories cannot comprehensively explain many findings. A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without requiring doctors to use tools to help pull the baby out. The mother must push to move her baby down her birth canal until its born. Labour is initiated through drugs or manual techniques. Normal Spontaneous Delivery NURSING CHECKLIST University Our Lady of Fatima University Course health assessment (NCMA121) Academic year2021/2022 Helpful? When about 3 or 4 cm of the head is visible during a contraction in nulliparas (somewhat less in multiparas), the following maneuvers can facilitate delivery and reduce risk of perineal laceration: The clinician, if right-handed, places the left palm over the infants head during a contraction to control and, if necessary, slightly slow progress. Methods include pudendal block, perineal infiltration, and paracervical block. When a woman goes into labor without the aid of any labor inducing drugs or methods, and is able to deliver the baby without requiring a doctor's aid through cesarean section, vacuum extraction, or with forceps, this is known as a normal spontaneous vaginal delivery . Use OR to account for alternate terms Labor usually begins with the passing of a womans mucous plug. After delivery of the infant and administration of oxytocin, the clinician gently pulls on the cord and places a hand gently on the abdomen over the uterine fundus to detect contractions; placental separation usually occurs during the 1st or 2nd contraction, often with a gush of blood from behind the separating placenta. Labor begins when regular uterine contractions cause progressive cervical effacement and dilation. o [ pediatric abdominal pain ] Treatment depends on etiology read more , which is a leading cause of maternal morbidity and mortality. Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women wish to bear down and push or if labor is advanced and there is no time for epidural injection. Contractions may be monitored by palpation or electronically. This is the American ICD-10-CM version of O80 - other international versions of ICD-10 O80 may differ. Towner D, Castro MA, Eby-Wilkens E, et al: Effect of mode of delivery in nulliparous women on neonatal intracranial injury. All rights reserved. After the anterior shoulder delivers, the clinician pulls up gently, and the rest of the body should deliver easily. Clin Exp Obstet Gynecol 14 (2):97100, 1987. Because of the perceived health, economic, and societal benefits derived from vaginal deliveries . Delivery bed: a bed that supports the woman in a semi-sitting or lying in a lateral position, with removable stirrups (only for repairing the perineum or instrumental delivery) . N Engl J Med 341 (23):17091714, 1999. doi: 10.1056/NEJM199912023412301, 4. An arterial pH > 7.15 to 7.20 is considered normal. J Obstet Gynaecol Can 26 (8):747761, 2004. https://doi.org/10.1016/S1701-2163(16)30647-8, 2. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. The coordinator of this series is Larry Leeman, MD, MPH, ALSO Managing Editor, Albuquerque, N.M. It can also be called NSD or normal spontaneous delivery, or SVD or spontaneous vaginal delivery, where the mother delivers the baby . Exposure therapy is an effective intervention for anxiety-related problems. We also searched the Cochrane database, Essential Evidence Plus, the National Guideline Clearinghouse database, and the U.S. Preventive Services Task Force. An episiotomy incision that extends only through skin and perineal body without disruption of the anal sphincter muscles (2nd-degree episiotomy) is usually easier to repair than a perineal tear. In low-risk deliveries, intermittent auscultation by handheld Doppler ultrasonography has advantages over continuous electronic fetal monitoring. Walsh CA, Robson M, McAuliffe FM: Mode of delivery at term and adverse neonatal outcomes. (2013). If it is, the clinician should try to unwrap the cord; if the cord cannot be rapidly removed this way, the cord may be clamped and cut. When the head is delivered, the clinician determines whether the umbilical cord is wrapped around the neck. Cord clamping. Some read more ). Place the tip of the middle finger at the sacral promontory and note the point on the hand that contacts the pubic symphysis (Figure 162-1B). Consider delayed cord clamping in all deliveries not requiring emergent Resuscitation. Spontaneous vaginal delivery. Use to remove results with certain terms A vaginal examination is done to determine position and station of the fetal head; the head is usually the presenting part (see figure Sequence of events in delivery for vertex presentations Sequence of events in delivery for vertex presentations ). Labor can be significantly longer in obese women.9 Walking, an upright position, and continuous labor support in the first stage of labor increase the likelihood of spontaneous vaginal delivery and decrease the use of regional anesthesia.10,11. Also, delivering between contractions may decrease perineal lacerations.30 Routine episiotomy should not be performed. Induction is recommended for a term pregnancy if the membranes rupture before labor begins.4 Intrapartum antibiotic prophylaxis is indicated if the patient is positive for group B streptococcus at the 35- to 37-week screening or within five weeks of screening if performed earlier in pregnancy, or if the patient has group B streptococcus bacteriuria in the current pregnancy or had a previous infant with group B streptococcus sepsis.5 If the group B streptococcus status is unknown at the time of labor, the patient should receive prophylaxis if she is less than 37 weeks' gestation, the membranes have been ruptured for 18 hours or more, she has a low-grade fever of at least 100.4F (38C), or an intrapartum nucleic acid amplification test result is positive.5, The first stage of labor begins with regular uterine contractions and ends with complete cervical dilation (10 cm). Because of possible health risks for the mother, child, or both, experts recommend that women with the following conditions avoid spontaneous vaginal deliveries: Cesarean delivery is the desired alternative for women who have these conditions. In particular, it is difficult to explain the . Obstet Gynecol 121(1):122128, 2013. doi: 10.1097/AOG.0b013e3182749ac9. In such cases, an abnormally adherent placenta (placenta accreta Placenta Accreta Placenta accreta is an abnormally adherent placenta, resulting in delayed delivery of the placenta. Then if the mother and infant are recovering normally, they can begin bonding. The diagonal conjugate refers to the distance from the inferior border of the pubic symphysis to the sacral promontory (Figure 162-1A).The normal diagonal conjugate measures approximately 12.5 cm, with the critical distance being 10 cm. The average length of the third stage of labor is eight to nine minutes.38, The greatest risk in the third stage is postpartum hemorrhage, which was recently redefined as 1,000 mL or more of blood loss or signs and symptoms of hypovolemia.39 The median blood loss with vaginal delivery is 574 mL.40 Blood loss is often underestimated by as much as 30%, and underestimation increases with increasing blood loss.41 The risk of hemorrhage increases after 18 minutes and is six times greater after 30 minutes.38 Postpartum hemorrhage is most commonly caused by atony (70% of cases).42 Other causes include vaginal or cervical lacerations, uterine inversion, retained products of conception, and coagulopathy.42 Table 5 lists risk factors for postpartum hemorrhage.42, Active management of the third stage of labor (AMTSL), which is recommended by the World Health Organization,43 is associated with a reduction in the risk of hemorrhage, both greater than 500 mL and greater than 1,000 mL, maternal hemoglobin level of less than 9 g per dL (90 g per L) after delivery, need for maternal blood transfusion, and need for more uterotonics in labor or in the first 24 hours after delivery.44 However, AMTSL is also associated with an increase in postpartum maternal diastolic blood pressure, emesis, and use of analgesia and a decrease in neonatal birth weight.44 Although AMTSL has traditionally consisted of oxytocin (10 IU intramuscularly or 20 IU per L intravenously at 250 mL per hour) and early cord clamping, the most important component now appears to be the administration of oxytocin.43,44 Early cord clamping is no longer a component because it does not decrease postpartum hemorrhage and may be associated with neonatal harm.35,44 Delayed cord clamping may avoid interfering with early transplacental transfusion and avoid the increase in maternal blood pressure and decrease in fetal weight associated with traditional AMTSL.44 More research is needed regarding the effects of individual components of AMTSL.44, Cervical, vaginal, and perineal lacerations should be repaired if there is bleeding. Oxytocin can be given as 10 units IM or as an infusion of 20 units/1000 mL saline at 125 mL/hour. A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without requiring doctors to use tools to help pull the baby out. Each woman may have a completely new experience with each labor and delivery. Read more about the types of midwives available. A tight nuchal cord can be clamped twice and cut before delivery of the shoulders, although this may be associated with increased neonatal complications, including hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, cerebral palsy, and death according to case reports. N Engl J Med 341 (23):17091714, 1999. doi: 10.1056/NEJM199912023412301, 4. The length of the labor process varies from woman to woman. Compared to other methods of childbirth, such as a cesarean delivery and induced labor, its the simplest kind of delivery process. Some read more ). Some read more ) tend to be more common after forceps delivery than after vacuum extraction. o [ abdominal pain pediatric ] brachytherapy. The most prevalent approach to training novices in this skill is allowing them to perform deliveries on actual laboring patients under the direct supervision of an experienced practitioner. An alternative to delayed clamping in premature infants is umbilical cord milking, which involves pushing blood toward the infant by grasping and squeezing (milking) the cord before it is clamped. If she cannot and if substantial bleeding occurs, the placenta can usually be evacuated (expressed) by placing a hand on the abdomen and exerting firm downward (caudal) pressure on the uterus; this procedure is done only if the uterus feels firm because pressure on a flaccid uterus can cause it to invert Inverted Uterus Inverted uterus is a rare medical emergency in which the corpus turns inside out and protrudes into the vagina or beyond the introitus. Learn about the types of episiotomy and what to expect during and after the. Healthline Media does not provide medical advice, diagnosis, or treatment. Do not discontinue an epidural late in labor in an attempt to avoid assisted vaginal delivery. Many obstetric units now use a combined labor, delivery, recovery, and postpartum (LDRP) room, so that the woman, support person, and neonate remain in the same room throughout their stay. Sequence of events in delivery for vertex presentations, Cargill YM, MacKinnon CJ, Arsenault MY, et al, Fitzpatrick M, Behan M, O'Connell PR, et al, Towner D, Castro MA, Eby-Wilkens E, et al, Marcaine, Marcaine Spinal, POSIMIR, Sensorcaine, Sensorcaine MPF , Xaracoll, 7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme, Aspercreme with Lidocaine, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Ela-Max, GEN7T, Glydo, LidaMantle, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , Lidomar , Lidomark, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido. It is used mainly for 1st- or early 2nd-trimester abortion. Some read more ). True B. Obstet Gynecol Surv 38 (6):322338, 1983. If appropriate traction and maternal pushing do not deliver the anterior shoulder, the clinician should explain to the woman what must be done next and begin delivery of a fetus with shoulder dystocia Shoulder dystocia Fetal dystocia is abnormal fetal size or position resulting in difficult delivery. takingcharge.csh.umn.edu/explore-healing-practices/holistic-pregnancy-childbirth/how-does-my-body-work-during-childbirth, mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancy/art-20044568, mayoclinic.org/diseases-conditions/placenta-previa/basics/definition/con-20032219, Debra Sullivan, Ph.D., MSN, R.N., CNE, COI, What Are the Symptoms of Hyperovulation?, Pregnancy Friendly Recipe: Creamy White Chicken Chili with Greek Yogurt, What You Should Know About Consuming Turmeric During Pregnancy, Pregnancy-Friendly Recipe: Herby Gruyre Frittata with Asparagus and Sweet Potatoes, The Best Stretch Mark Creams and Belly Oils for Pregnancy in 2023, Why Twins Dont Have Identical Fingerprints. Call your birth center, hospital, or midwife if you have questions while you are in labor. This content is owned by the AAFP. Episiotomy is associated with more severe perineal trauma, increased need for suturing, and more healing complications.31. The infant is thoroughly dried, then placed on the mothers abdomen or, if resuscitation is needed, in a warmed resuscitation bassinet. This is the American ICD-10-CM version of Z37.0 - other international versions of ICD-10 Z37.0 may differ. 2005-2023 Healthline Media a Red Ventures Company. The woman's partner or other support person should be offered the opportunity to accompany her. Students also viewed Health Assessment Form for Student 02 Guillermo, Dairon V. (VRTS111 Broadening Compassion) We do not control or have responsibility for the content of any third-party site. A tight nuchal cord can be clamped twice and cut before delivery of the shoulders, or the baby may be delivered using a somersault maneuver in which the cord is left nuchal and the distance from the cord to placenta minimized by pushing the head toward the maternal thigh. Copyright 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. If anesthesia is local (pudendal block or infiltration of the perineum), forceps or a vacuum extractor is usually not needed unless complications develop; local anesthesia may not interfere with bearing down. Some read more ). Eye antimicrobial (1% silver nitrate or 2.5% povidone iodine) . With thiopental, induction is rapid and recovery is prompt. Midwives provide emotional and physical support to mothers before, during, and even after childbirth. If fetal or neonatal compromise is suspected, a segment of umbilical cord is doubly clamped so that arterial blood gas analysis can be done. Out of the nearly 4 million births in the United States in 2013, approximately 3 million were vaginal deliveries.1 Accurate pregnancy dating is essential for anticipating complications and preparing for delivery. The head is gently lifted, the posterior shoulder slides over the perineum, and the rest of the body follows without difficulty. Both procedures have risks. If you're seeking a preventive, we've gathered a few of the best stretch mark creams for pregnancy. Use for phrases A C-section is a surgical procedure where your provider makes an incision (cut) in your abdomen and delivers the baby in an operating room. However, exploration is uncomfortable and is not routinely recommended. When describing how a pregnancy is dated, by last menstrual period means ultrasonography has not been performed, by X-week ultrasonography means that the due date is based on ultrasound findings only, and by last menstrual period consistent with X-week ultrasound findings means ultrasonography confirmed the estimated due date calculated using the last menstrual period. LeFevre ML: Fetal heart rate pattern and postparacervical fetal bradycardia. Rarely, nitrous oxide 40% with oxygen may be used for analgesia during vaginal delivery as long as verbal contact with the woman is maintained. Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) dedicated to using leading-edge science to save and improve lives around the world. The fetal head comes below the pubic symphysis and then extends. When epidural analgesia is used, drugs can be titrated as needed during the course of labor. 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